MedicaidPrior AuthMedium impact
Newsletter Vol. 10, No. 35
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
Jan 18, 2000
We identified it
Jun 20, 2026
Summary
New Jersey implemented enhanced Prospective Drug Utilization Review (PDUR) monitoring for oral and nasal pharmaceutical inhalers effective January 18, 2000. Claims exceeding maximum daily dosage standards will trigger Edit Code 535 and may require prior authorization from First Health Services. This affects pharmacy claims for beneficiaries 12 years and older across Medicaid, General Assistance, NJ KidCare, PAAD, Cystic Fibrosis, and AIDS Drug Distribution programs.
Action Required
Pharmacy providers and billing teams must: (1) On or after January 18, 2000, implement system edits to flag claims with daily quantities exceeding the maximum dosage standards listed in the attached drug product table using Edit Code 535; (2) Update billing software to recognize Edit Codes 927, 928, 929, and 423 as they apply to inhalant claims; (3) Establish process to request prior authorization from First Health Services before submitting claims that exceed maximum daily quantities to avoid Edit 423 denials; (4) Train pharmacy staff to verify patient age (12+) and compare dispensed quantities against the Maximum Day Supply standards for all brand and generic formulations listed; (5) Apply the existing 75% early refill rule to these claims. Failure to obtain prior authorization will result in claim denials. Contact Chief of Pharmaceutical Services at (609) 588-2724 or Unisys Pharmacy Consultant at (609) 588-6039 for questions.